Conduct disorder is not caused by bad parenting

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I’m sure this adorable child never behaves badly.

 

Conduct disorder is when a child keeps behaving in a particularly bad way.  Behaviours indicative of conduct disorder in young children include lying, bullying, making threats, starting fights, damaging property, stealing, hurting animals, hurting people, and starting fires.  For older children, the list also includes sexual assault, staying out at night, and using weapons.

A recent longitudinal study in Massachusetts found that mothers’ level of warmth, over-reactivity or laxness had little to no association with early symptoms of conduct disorder in preschool children.  The researcher selected 197 children whose parents reported disruptive behaviour and followed them for three years, from ages 3-6.  Signs of disruptive behaviour were consistent across time as were parenting styles, but the two were mostly unrelated.  If anything, the study suggests that the children’s behaviour may negatively affect mothers’ warmth and lead them to over-react, rather than the other way around.  But even that’s a very weak relationship.

This finding goes against a deep running belief in our society that parents are to blame for their children’s behaviour.  It’s never been entirely clear whether the problem is supposed to be coercive parenting that sets a bad example or too lax parenting that makes children run wild.  But now it turns out it’s neither.  I’m not sure if it’s good news though because it would be nice to think that we could cure conduct disorder with no more than our own good behaviour.  The author does point to other studies that claim parenting makes a difference for older children, and for other behavioural problems such as defiance and attention-seeking.

Meanwhile, two researchers who interviewed snowboarding mothers note with dismay that motherhood leads to more cautious behaviour.  It’s true, it does.  Yes, voluntary risk taking can be a joyful thing, and yes, mothers are often depressed.  And yet… snowboarding mothers!  Snowboarding while pregnant!  I feel the shockingness, but maybe they’re right – maybe we restrict ourselves too much.

Mothers who get a positive CNV result

sleep-907769_1920When you’re pregnant, you can do a genetic test that gives you a Copy Number Variant (CNV) for your baby.  If the result is negative, all is probably well.  If it’s positive, however, it means that something could go wrong.  Or maybe not.  They don’t really know.  Nobody can really tell you what it means exactly, but it’s bad.  Maybe.

A recent study followed up 23 women who got positive CNV results during their pregnancies and went ahead to have their babies.  At 6-12 months, most of the babies (18 out of 23) were developing normally (the study didn’t say what was happening with the other 5).  Most of the mothers (16 out of 23) were very anxious about their children because of the test result.  Its ambiguous warning made them feel anxious about everything, from how much their baby smiled, to sleeping habits, to whether or not they would simply stop breathing.  Here are some quotes from the interviews:

Last night she was up crying for an hour and instead of knowing okay, shes teething, I go to does she have a kidney infection? Is there something wrong with her lung? Did she lose hearing in her other ear and now shes freaked out? So it is a constant…I try not to overreact but my mind is going all these places and then I can’t do anything about it—I cant ask anyone because nobody knows.
Once or twice it’s crept into my head where I’ve been like ’what if this microarray resultlike there’s something wrong with her and we don’t know and one day she just has SIDS and stops breathing. She’s got such a strangely mellow temperament so I think, ‘is there something wrong with her that she’s just so lovely’—which makes no sense.
To some extent this seems like ordinary, obsessive maternal concern with a bit of extra motivation.
But what about those handful of mothers who got the positive CNV result but who are not continually anxious?  How is that possible?
  • For one mother, it was her second child to have this positive test result.  She had been very anxious with the first one, who had ended up having no problems, and so she wasn’t so concerned for the second one.
  • One mother found that she had the same chromosomal condition herself, and because she was fine she didn’t worry about her child.
  • One mother had anticipated specific physical symptoms associated with a particular disorder, and when her baby looked normal at birth, she was no longer concerned.
  • Three mothers had babies with immediate health problems that they were dealing with, and so the CNV result was kind of irrelevant to them.

But most mothers were anxious and watchful in particular ways.  Some mothers had even started interventions with their children even though there were no signs of abnormal development (yet!).  Mostly, they relied on their health providers for assessments and on comparisons with other children.

The mothers interviewed for the study tended to speak in a positive way about the test.  One mother said,  I’m such a proponent of this testing and I talk about it with anyone that will listen to me.”   They know more about the test than I do; I didn’t get it when I was pregnant.  From the outside, though, the advantages of the test are not really obvious.  It’s not as if we’re not vigilant about our children’s development anyway.  What difference does it really make apart from making you feel bad?

Shaming EU mothers who buy formula

A mother shopping at Tescos in the UK was refused a free parking voucher because she was buying infant formula.  If she had been buying beer or doughnuts or baby shampoo or almost any other product, she would have received the voucher.  Only cigarettes and infant formula were excluded from the voucher program, in accordance with EU regulations which forbid the advertising and promotion of those products.

Laura Leeks felt shamed and guilt-tripped by the staff at Tescos and felt the need to explain the reasons why she was formula feeding rather than breastfeeding in a detailed personal account on their Facebook page.   I hope Tescos listens to her and changes their policies.  Giving parking vouchers for any product does not seem like promotion of particular products and an overly strict application of the regulation.

I saw the opposite of this a few weeks ago in Peru.   Marketers for Pediasure, a product from the US company Abbott, came through the waiting rooms of the paediatric section of the hospital, where mothers were waiting for their infant check-ups, handing out leaflets and balloons for children.  Their leaflet explained that Pediasure would help children grow taller!  Two centimetres every 120 days!

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These promises were based on a research paper, cited on the back of the leaflet.    The research paper was produced by employees of Abbott.  They recruited 200 children in Manila, chosen specially because they were small and thin for their age.  At baseline, most of them were eating less than the recommended daily calorie intake.   Then, the Abbott employees gave the parents free formula and asked them to feed it to their children every day, boosting their diets by 450 kcal every day for a year.

Turns out, giving underfed children extra calories makes them grow slightly bigger!  The weight for height percentiles of their sample averaged 16% at baseline (very thin) and 30% at the end (thin).  Height for age percentiles averaged 14% at the beginning (small for their age) and 17% at the end (small for their age), a negligible difference.

How would those results compare to giving those children calories from another source – say, fresh food – for a year?  We will never know.  Obviously, Abbott employees have no interest in making such a comparison.

So yeah.  Let’s restrict the marketing opportunities of these sorts of companies.  I’m sorry that Laura Leeks and other EU mothers got shamed though.

 

Most US mothers aren’t screened for depression

It turns out that most US clinicians don’t screen parents for depression.  Researchers followed seven clinics in Philadelphia over a 20 month period.  Clinicians were supposed to screen all caregivers who came for well-child visits between 12-36 months.  Over 8000 families were eligible for screening but only a minority (21%) were actually screened.

When asked why not, the main answer was time pressure.  One clinician said,

It is a tough question to ask … And when you’re behind and you’re going into a room and you have ten minutes, and you’re running an hour behind, it’s sort of like, oh, I don’t even want to open up that can of worms …

It’s a tough two questions.  The researchers used PHQ-2 (Patient Health Questionnaire) which only has two items relating to mood:

  1. Over the past two weeks, how often have you been bothered by little interest or pleasure in doing things?
  2. Over the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?

One particular comment caught my eye:

“One of the things about screening is that you shouldn’t screen unless you can do something about it. And so the doing something about it is hard, and that’s probably where people push back.”

This is something that has always bugged me about the rhetoric surrounding maternal depression.  You must ask for help!  It’s really important that we detect it!  But less clear is what kind of help the mother is to receive, whether it will make a difference, and what the costs are in getting that help.

Mothers too are under time pressure.  They are attention and sleep deprived.  They too a probably reluctant to open a “can of worms” and create drama by owning up to a depression diagnosis.  The researchers cite previous studies that show that even when mothers screen positive to depression, most of them are not referred onwards.  When the mothers themselves are required to set up the appointments for mental health, the rates are even lower.

I suppose the question is, does intervention work and is it worth the bother?  Lots of clinicians and parents seem to think that it is not, but are they right?  Because the public rhetoric of postpartum depression seems definitely otherwise.

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Reference

Guevara, J. P. & Gerdes, M. & Rothman, B. & Igbokidi, V. & Doughterty, S. & Localio, R. & Boyd, R. C. “Screening for Parental Depression in Urban Primary Care Practices: A Mixed Methods Study.” Journal of Health Care for the Poor and Underserved, vol. 27 no. 4, 2016, pp. 1858-1871. Project MUSE, muse.jhu.edu/article/634633

Stories we create about mothers

adoption-177427_1280.jpgA Dutch woman travelled to South Korea because she wanted to find her birth mother.  She ended up on a television show about reuniting people.  A call was put out for her mother, who phoned in and the pair were reunited.  They did not have a language in common and so Hosu Kim, a sociology and anthropology professor based in the US, was called in to interpret for the show.  Kim wrote about her experiences on the show as part of her new book which is all about the transnational adoption of Korean babies.

The producers of the television show deliberately scripted the reunion, and Kim noted that the experience of the birthmother was falsified in several ways for the sake of television.  The show made it seem as if the birth mother – or, the virtual mother as Kim likes to call her – recognized her daughter’s face as soon as she saw it on the screen and called in at once.  In fact, it was a friend of hers who recognized her name and who contacted the show for her.  On the day the reunion was screened, the producers called the mother.

Emotionally, the narrative of the show was that the mother had been longing for her daughter all this time, that ill health and poverty had forced her to give up her daughter to a better life, and that she was delighted to be reunited.  But the truth was not like that, it was more ambiguous.  The mother had been married at the time of the birth and it was never really clear why she had chosen to leave her baby behind in hospital.  She has five other daughters, and they had never been told about the other sister.  The conversations that Kim helped interpret after the screening of the show she described as “confusing, frustrating, and unsatisfying”.

Kim describes two imaginary cultural figures of birthmothers:

The first figure is of an elderly, sacrificing mother who awaits her adopted child’s eventual return in order to reclaim her motherhood; the second figure is of an unmarried, sexually irresponsible woman who has no viable option except to relinquish the child to adoption.

You know, when I first read this, I felt angry and indignant at the idea of women being judged as too irresponsible to keep their children.  How outrageous!  Why, if those mothers did not have sufficient emotional, social and economic support to raise their children, then it was the fault of society in general!  As Hrdy and others have explained, the work of raising a child is simply too much for a single person.  There needs to be a team (a village!) backing her up.

But, you know, while I am still a mother of young children, retirement seems just a stone throw away, really, and young women seem like a different generation.  It occurs to me that in societies without strong government welfare, the work of caring for young, irresponsible mothers and their offspring would have fallen to people like me!  To middle-aged, middleclass women who lived in the area with their own children.  We would have had to cough up money, food, babysitting time, concern, just to get those babies through to school age without any disasters.  And we would have resented it!  There’s enough work for us to do already without irresponsible young women not taking enough care to avoid pregnancy in the first place!  Hmm.  Obviously, the situation is quite different nowadays because of abortion, contraception and government benefits.  It’s none of my concern whether people get pregnant or not.  So I have the luxury of being liberal minded.

Television is all about selling a story, and Kim writes in an engaging way herself.  Still, there’s something very intriguing about the idea that we’re all culturally and politically invested in stories of individual mothers.  I’m not Korean, and Kim lost me a bit when she talked about Korean history and culture, but I definitely felt invested in how the story of this birthmother was framed.  Her story is my story!  Except of course, it isn’t even remotely my story.  So why does it feel like that?

Reference

Kim, Hosu. “Television Mothers: Birth Mothers Lost and Found in the Search-and-Reunion Narrative.” Birth Mothers and Transnational Adoption Practice in South Korea. Palgrave Macmillan US, 2016. 115-143.

 

Depressed mothers in Qatar

Another report has been published about postpartum depression, this time from Qatar.  The researchers gave questionnaires to 285 postpartum mothers from South Asian backgrounds and found that about 1 in 3 were depressed.  “Depression” was considered to exist if the scores on the Edinburgh Postnatal Depression Scale were equal or greater than 10. In other studies cited for comparison, the cut-off was higher, at 12 or 13, but the authors failed to mention this.  Instead, they said, “the prevalence of depressive symptoms in this study was higher than in other regional studies and sends an alarming message to policy makers and health professionals alike.”  This comes across to me as sheer dishonesty.  Of course you will get a higher prevalence if your cut-off threshold is lower!

Also, just in general, these questionnaire studies can be sketchy.

https://www.flickr.com/photos/yimhafiz/7271752756
A shopping village in Doha with a fake sky

 

The most interesting part of this article was the association between postpartum “depression” and “a history of anxiety” during the current pregnancy.  It was the strongest association: mothers with a history of anxiety during the pregnancy were four times more likely to develop postpartum depression than mothers without such a history.  Why?

The researchers decline to explain how this history of anxiety was measured, but given that their questionnaire was short (22 items), including all demographic questions, it was probably a single item.  Just over half the mothers (159) reported anxiety during pregnancy (132 did not report anxiety, which adds up to more than the 285 mothers who were interviewed, but let’s just ignore that for now).

Maybe the mothers were asked, “Did you experience any anxiety during your pregnancy?”  Of course, ALL mothers experience anxiety during pregnancy, but only half said yes.  Why?  What were they anxious about?  Why did the other half say no?

The Edinburgh Postnatal Depression Scale also includes several questions about anxiety, for instance, “I have been anxious or worried for no good reason.”  No good reason.  Maybe that evaluation was implied in the general question about anxiety.  Were you [unusually or unnecessarily] anxious during your pregnancy?

The ambiguity of these questions makes them vulnerable to response bias.  A mother who thinks she has no good reason for the anxiety she’s feeling after her baby is born (after all, the baby is fine, right?  She should be happy) might also say that yes, she was anxious during her pregnancy (even though there turned out to be nothing to worry about!).  A mother in a different frame of mind might say no, I have not been anxious for no good reason (after all, I’ve just had a baby – what better reason could there be?) and no, I was not anxious during my pregnancy (no more than might be expected, anyway).  And hey ho, there’s a correlation between prenatal anxiety and postnatal depression!

Even so, it was interesting to read about South Asian mothers in Qatar.  For working age adults there, there are about 4 men to every women.  That’s because most of the population is immigrants who are there to work, and most of these are men.  There is also a number of female immigrants who are domestic workers and as such not subject to the same rights and protections as other workers.  However, I think the mothers in this sample were not domestic workers, because of those who were working, their incomes were much higher.  Also, domestic workers in Qatar tend to be from the Philippines and Indonesia rather than South Asia.

Nor is the law in Qatar particularly friendly to women.  Women get arrested and jailed for reporting rapePregnant women who were unmarried at the time of conception get put in jail, and abortion is mostly illegal.

What are those mothers doing in Qatar?  What are they anxious about?  How long are they going to stay there for?  Best wishes to them and their babies, in any case.

Reference

Mohamed, H. (2016). Prevalence of postnatal depression and associated risk factors among South Asian mothers living in a newly developing country. Asian Journal of Pharmaceutical and Clinical Research.

http://innovareacademics.in/journals/index.php/ajpcr/article/viewFile/12900/7892

Uneducated mothers cannot “transcend their everyday experiences”

hb_29_100_48In Brazil, researchers interviewed six mothers and concluded that uneducated mothers find it difficult “to transcend their everyday experiences”.  Educated mothers, on the other hand, were able to consider complex aspects of their interactions with their babies and thereby “transcend” primary care considerations.

They reached this conclusion with the help of a French software analysis package called Alceste, which can eat up any kind of text and spit back out blocks of words categorized by their proximity.  The current researchers plugged in their six interviews and the computer spat back two categories.  The first included words like PUT, SLEEP, TIME, WALK and CRYING; the second category included words like ISSUE, MOTHER, THINK, EXPERIENCE, and BOND.  Without any further analysis, the researchers concluded that the first category was the everyday of the uneducated, whereas the second category was the transcendence of the educated.  It seems as if this was a conclusion that the researchers had in mind before they started the study.

One of the mothers in the study, the least educated, was 32 years old, with 5 children and an income two thirds of the minimum wage.  She is likely to be under immediate day-to-day pressures, and more so than the post-graduate mother of two with an income almost ten times greater.  She’s going to have less time to sit about ruminating about the quality of her bonding experience with her baby.  If there’s a difference in the way the two mothers talking about their relationships with their children, there’s no reason to suppose that it’s formal education that makes the difference.

The researchers seemed to be frustrated at the way some mothers (especially the uneducated ones) answered their questions:

It was noticed, when interviewing mothers, that some of them had difficulty in answering the questions formulated from reflections, getting quite restricted to the facts and personal experiences of the “here and now”. So they spoke from their practices and held in the minutiae of routine care for their babies, often at the expense of what was required of them.

This is perhaps the most interesting part of the study.  Mothers were asked about bonding with their babies, the parent-child relationship, what’s important for development.  In response, they spoke about the here and now.  They did not speak in the abstract.  They did not talk about theories or beliefs, even though that’s what the researchers seemed to want from them.

Maybe that’s because, after all, there is only the here and now when it comes to mothers and children.  When people talk about motherhood in abstract terms, it seems so bland and irrelevant compared to the immediacy of a child demanding something.  Maybe bonding is like culture – it only exists to the observer.  To the mother in the middle of it, there’s no bonding, there’s only getting up at night in response to a crying baby – there’s only constant vigilance to know where the baby is – there’s only patience as a rough toddler tries to climb on you while you’re picking up the laundry.

The researchers wanted their mothers to transcend the everyday, and those with an education were able to oblige to some extent.  But what does that tell us about motherhood?

References

Oliveira, A. D., Chaves Maia, E. M., & Alchieri, J. C. (2016). What do mothers say about the mother and baby relation?. Journal of Nursing UFPE on line, 10(9), 3212-3222